15 Comments

Alright, here it goes. I am going to say probable inferior-lateral AMI, even though there is evidence of a LBBB, if that is new (as a patient with "nil" cardiac history would have) then that is another indicator. I say inferior because of the ST elevation in II, III, AVF, and Lateral because of V5-6. I know that a BBB can confound elevation/depression, but my guess is that the presumably new LBBB and ST elevation in 2 contiguous leads (in 2 different places) are 2/3 criteria you are looking for… I look forward to being corrected! Is it criteria for R sided involvement? As far as treatment, I would start O2, monitoring, serial 12-leads to look for progression, a Right sided 12 lead/15 lead, heck, maybe even an "18 Lead" to check the posterior while I am at it. BP and HR seem a little low for someone in this much pain, (so is the conduction system also affected?) so I would probably give a fluid bolus before any nitro as there is no evidence of pulmonary edema, especially if there is evidence of R sided involvement. Aspirin, and fentanyl for pain management, rapid transport to a PCI capable center.

Going out on a limb here but would the three criteria be:1) Concordant ST elevation in II, V4, V5, V6.2) Concordant ST depression in V1, V2, V3.3) Discordant ST and T waves with ST elevation > 0.2 depth of the S wave in III and aVF.Seems like this one definitely meets STEMI criteria in LBBB.Treatment includes IV fluids and 15 LPM O2. Seems like this has inferior involvement so I would hold off on Nitro. 324 mg ASA and morphine or fentanyl for pain management. My protocol calls for 600 of Plavix in confirmed STEMI so I'd probably be dropping that as well. Right now vitals look ok but I would be keeping a close eye on them during transport. Call ahead to the cath lab would also happen during report.

The diagnosis is straight forward inferolateral STEMI ( typical presentation of the chest pain + typical ECG changes) the culprit artery is the LCX . Don't forget to rule out Right ventricular involvement by V4R ..Treatment is as for all STEMI with Aspirin , Clopidogrel , O2, be careful when using GTN or morphine and Beta blockers since this type of infarction tend to be complicated with hypotension, heart failure or AV block and of course PCI as soon as possible.

I'm going to say inferio-lateral STEMI based on the criteria already outlined. I would like to do a right sided ECG as well, but I'm trying to figure out how V4R should look w/ a LBBB. If the left bundle is blocked, conduction is cell to cell causing the wide QRS. It seems like the "normal" LBBB I am familiar with has a negative complex in V4 w/ a discordant T wave. The normal 12 lead ECG seems to have a positive complex in V4 and if you do a V4R, the complex is negative because the vector is going away from the electrode, right?. This complex looks positive already, so what should be expected? Am I thinking too much into this?

Thanks for the comments, everyone! You guys are all on track. One small comment, because this point is often misunderstood. The ST-depression in the right precordial leads (V1-V3) is actually concordant because it's in the same direction as the terminal deflection of the QRS complex.Tom

Ok so the reason we consider depression in V1-3 as a positive STEMI is that it is a presumed posterior one, why do we need that rule? Wouldn't the other two rules apply to the posterior leads?In other words, wouldn't the standard adage of "Anterior depression can be posterior elevation so check the back" apply here making things even MORE sensitive (checking for posterior elevation vs. anterior depression that isn't a reciprocal change)?

Tom, I think you may have started a revolution of MI identification in the presence of LBBB. I dare say that you have provided more information on this topic than anywhere else I have seen. The days of “its a LBBB, unreadable” are hopefully over!!! Now, if you can get the ER docs on the same page, you’d make some real headway.

Adam, I want to also give that suppot. My first STEMI call in the feild had a borderline LBBB .10-.12 somewhere. The changes had me concerned and so did the doc that refurred me to the PCI hospital 45 min out after the crew used the monitor to send the ekg to the nearest medical control doc. I ended up in trouble because the only thing found was the borderline BBB. Hx even made it likely to be new. I have been loving Dr Smith and education given on this. thankyou for you time!

You provided the diagnosis above article, so here is the my Tx until i learn something new. v4r, o2 maintain spo2 98-100% 2 lpm NC, ASA, Bilaterall large bore IVs,caution with NTG -nitro drip (on pump)titrate for pain b/p 100sys, fentanyl 25mcg titrate prn for pn not relieved by NTG/02/ASA and bp greater than 90-100 sys, serial 12 and right sided. if time permitted posterior leads but i know whats there from my 12 lead, NS 250-500ml bolus then titrate down to maintain bp above 90-100 sys. LS remain clear up to 3 L NS if needed. Early notification of STEMI. This area is not PCI but too far fron PCI to bypass ED treatment ( Note pci: 1hr 45 by ground, about 20 by air.). Check status of lifeflight. Meet in route to Local ED as indicated in protocol. D/C nitro if unable to maintain BP as it will almost immidiately wear off unlike SL dose.
Love feedback!! Sorry this one is so lone wanted to thank you.

Ben WallerWhy do we send so many people to a cardiac arrest?I am also a Battalion Chief in Tom's system. In addition to the AHA bullets he mentioned regarding high-quality CPR, our response is designed to provide fatigue-free CPR by sending enough people so that no one does CPR for more than 2 consecutive minutes. As for science, we believe strongly in it, but we also…
2016-12-08 11:29:19

Vince DiGiulioNo, doubling the paper speed will not reveal hidden P-wavesGreat tip! It's not much of an option prehospital, but one more thing I'll do when I'm in the ED and a patient has persistent tachycardia is look at the graphic trend of the patient's heart rate. Reentrant tachycardias will show a stable horizontal line (steady rate), often with a fairly abrupt onset/offset, while sinus…
2016-12-07 06:58:16

Vince DiGiulio59 Year Old Female: Intermittent Head Pain (Conclusion)Thanks! There's a couple of reasons why V7-9 might have been negative here: 1) Not all "inferoposterior" STEMI's show ST-elevation in V7-V9. Sometimes the ST-depression we see in V2 and V3 is reciprocal to the inferior STEMI and not really caused by posterior injury. 2) You'll notice that there is only subtle ST-depression in V3…
2016-12-07 06:55:27

Cardiac Care Show - Episode 1: Mechanical CPR - ECG Medical TrainingAdvanced Airway Management – Should Paramedics Be Intubating?[…] in the Resuscitation group on Facebook and the #FOAMed community on Twitter. Alongside tracheal intubation, response times, and fire-based EMS, this is one of the most controversial topics in prehospital […]
2016-12-04 18:26:57